Pediatric Coding Alert

Question: When I audit my physicians' subsequent hospital care notes, I frequently find notes that don't tell much about the patient's condition since the previous visit. The pediatrician might document something like, "Patient doing well." I'm afraid such notations won't meet the requirements of an interval history. How can I get the physicians to write notes that will stand upon review?

Iowa Subscriber

Answer: Since subsequent hospital care is on the Office of Inspector General's list of codes with high error rates, you're right to clean up your physicians' documentation now. When documenting interval history, ask your physicians to begin by answering two questions, suggested Kerin Draak, MS, RN, WHNP-BC, CPC, CEMC, COBGC, in "Hospital Coding ... Making the Rounds" at the 2010 American Academy of Professional Coders Annual Conference in Jacksonville, Fla. Why is the patient there? How has the condition changed since yesterday? If the physician answers the questions, the note should include two elements of history of present illness (HPI), which is a significant step toward supporting an interval history associated with either a 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity ...) or 99232 (... an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity ...).

Example: The pediatrician writes, "Patient feeling better since yesterday on Prednisone." The note includes duration (since yesterday) and modifying factors (on Prednisone): 2 elements of HPI. This amount would meet the HPI requirements for the first two levels of subsequent hospital care (99231-99232), and by itself, it would satisfy the documentation requirements for a problem focused interval history (99231).

The history requirements, including review of systems (ROS), for the three levels of subsequent hospital care include:

To support an expanded problem focused interval history (99232), the physician will also need to document an element of ROS. For instance, in addition to the sentence noted above, the physician might write, "Patient reports no fever or other adverse reactions," which suggests that the physician has inquired about the patient's constitutional symptoms.

For a detailed interval history (99233, ... detailed interval history; A detailed examination; Medical decision making of high complexity ...), the physician will need to add to both HPI and ROS.

The E/M documentation guidelines do not require any past medical, family, social history (PFSH) for categories of E/Mservices, such as subsequent hospital care, that include only an interval history.